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MEDICAL INSPECTION 
OF SCHOOLS. 



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MEDICAL INSPECTION 
OF SCHOOLS. 



By SAMUEL H. DURGIN, M.D. 



Kead at the Annual Meeting of the Massachusetts Medical Society, 
June 9, 1897. 







BOSTON: 

PRESS OF DAVID CLAPP & SON. 

1897. 



\ 



73i 



MEDICAL INSPECTION OF SCHOOLS. 



The influence of schools upon the spread of infectious 
diseases, and the need for the exercise of greater public care 
over the schools, have been much discussed within the last 
few years, and with nearly unanimous conclusions. I 
think we should all agree upon the fact that the collection 
of large numbers of people within small spaces, generally 
speaking, furnishes the most favorable opportunity for the 
spread of infectious diseases, but more particularly with 
school children whose susceptible age and familiar habits 
render them unusually liable to the incidence and extension 
of these diseases. We shall also agree that the infective 
agent is frequently present in our public schools and that 
it only remains to be shown by what means the infection is 
conveyed. 

For the purposes of this brief paper we shall need to 
consider but two of the most common and dreaded infec- 
tious diseases — diphtheria and scarlet fever, and perhaps 
diphtheria alone would be sufficient. 

It was thought from the beginning of our knowledge of 
diphtheria until within a few years, that it belonged in the list 
of what has been termed filth diseases, and with this view in 
mind Boards of Health followed out different lines of work 
for the purpose of proving or disproving the theory that 
this disease might be caused by any unsanitary conditions. 



4 MEDICAL INSPECTION OF SCHOOLS. 

In 1878 the Board of Health, with which I am identified 
in Boston, called for reports of cases of diphtheria, and for the 
last nineteen years we have examined every house in which a 
case of diphtheria was reported, and amongst other reasons 
to see what connection filth and defective drainage within 
buildings had with the prevalence of this disease, but 
with such negative results as to warrant the belief that 
it is scarcely, if at all, more likely to occur in the poorly 
constructed and badly kept houses than in the best. The 
percentage of defects found in connection with cases of 
diphtheria is found to be but slightly greater than that 
found when examining from house to house where no dis- 
ease or complaint has occurred. 

In 1882 we made an investigation to ascertain what 
connection there might be between cases or groups of cases 
of diphtheria and street gullies, perforated sewer covers, 
sewer outfalls, proximity to tide water flats, low damp 
ffround and high ground. Here again we found not even a 
suspicion of relation between cases of diphtheria and any 
of the suspected causes. On the other hand we are con- 
tinually reminded of the unmistakable direct or indirect 
connections between new cases of these diseases and other 
infected persons or rooms and articles which have become 
infected. AVe are forced to believe that the means by which 
children afflicted with diphtheria may and do create foci of 
infection in our school buildings as well as in their homes, 
and the facilities by which others may take on the infection 
from such foci, are both natural and easy. I think we are 
warranted in this belief by every process of reasoning and 
upon the facts connected with the disease. Diphtheria is, 
unquestionably, an infectious disease and may be commu- 
nicated directly from person to person, or indirectly through 
some intermediate object upon which the infective matter 
may have been lodged and where it may remain active for 
a longer or shorter time. The local manifestation of 



MEDICAL INSPECTION OF SCHOOLS. 

diphtheria is nearly always in the throat, Avhere Ave ha^'e 
the bacilli of the disease in abundance, mixed with the se- 
cretions of the throat and mouth, and in the most con- 
venient form to be transferred to any surrounding object. 
This infective matter is easily scattered and attached to 
things by coughing, sneezing and spitting, or by the fingers 
which perform a continual messenger service between the 
month and whatever may be touclied within the reach of 
such fingers. We have, for instance, a child suffering 
from diphtheria in school, not ill enough to attract special 
attention. He may be there for a day or two before the 
disease is discovered, with a mild, unrecognized case, or he 
may be there for a much longer time, in a condition for 
spreading the disease. During this time he may attach 
the infective matter to the desk, chair, books, slate, slate- 
pencil, lead-pencil, pen-holder, sponge, drinking cup, door- 
knob, door, window sill, banister, wainscotting, or to any- 
thing else which he may handle or touch after using his 
fingers about the mouth. The fact that these things may 
become infected with diphtheria in this way has been con- 
clusively shown in the laboratory by Professor Ernst. 

In kindergarten schools the danger of spreading the dis- 
ease by a single case is much greater, both by direct and 
indirect infection, because these children by virtue of the 
different processes of teaching are brought into much closer 
contact with each other, and they use a large number of ob- 
jects in common which are very liable to become infected. 
One unrecognized case under such circumstances may give 
rise to a dozen more, and without our being able to trace 
one of them to its particular source. 

The following account of a kindergarten teacher may be 
of interest at this point : 



" Regarding the contact of children Avith each other in 
kindergarten and the interchangeable use of material, it is 



6 MEDICAL INSPECTION OF SCHOOLS. 

as follows : The chairs for seating the children are small 
portable ones. These are carried from one place to another 
as the classes need them ; no one chair is allotted to any 
particular child, all are used in common. The tables at which 
the children sit are long enough for four or five children to 
sit at each. It is impossible to arrange so that each child 
may have the same chair or the same place at the table 
regularly. The material used is such that it is almost im- 
possible to let one child use any portion of it solely as his. 
We have but two dozen worsted balls with which to teach 
color, form and direction ; and we have seventy children to 
use the ball. It is the same with everything else. The 
blocks used are handled by two or three classes during the 
same day. The iron rings, wooden sticks, wooden planes, 
paste-board tablets, wooden beads, w^eaving needles and 
worsted needles are all used in common. The napkins used 
at lunch time are washed once a week and taken out before 
then if really soiled, otherwise tliey are folded and returned 
to the drawer ready for the next day. The picture books 
are enjoyed by all and the dolls are used at every recess. 
In playing the games the children stand holding hands on 
the ring, and when there is good attendance they are 
crowded. 

Many of the games bring them very close together, for 
instance : 

In playing the 'Birds Nest' the mother bird chooses six 
or more children who kneel upon the floor in a semicircle, 
she twines their arms about each other to imitate weaving 
the nest. She then chooses three children who are put 
close together, necessarily, in the nest and then the game 
proceeds. This is a typical bird game and is very pretty, 
but in time of epidemic of throat diseases we do not like 
to play it in our kindergarten as it brings the heads so near 
each other. There are other games, of course, which do 
not need such close proximity as the one described, but all 
the games are for two or more children to take part in and 
they are generally in contact in some way if only holding 
hands." 

Xumerous instances have come under our observation 
where a child has been found in school suftering from an 



MEDICAL INSPECTION OF SCHOOLS. 7 

infectious disease by the medical inspector of schools, and 
sent home ; this case has been followed in due time by- 
other cases in children whose only discoverable exposure 
was that which occurred in the school room. Fresh evi- 
dence of such exposure and of its effects has been brought 
to my attention within a few weeks occurring in the 
service of Dr. Arnold, one of our school inspectors. An 
epidemic of diphtheria occurred in a primary school in 
which there were forty pupils, fourteen of whom were at- 
tacked with diphtheria within a period of eighteen days, all 
from one room. Of the fourteen cases seven were discov- 
ered by the school inspector and three of these only by cul- 
tures. All suspicious cases were dismissed from school 
May 5th, and recommended to the care of their family phy- 
sicians. The next morning every pupil was examined and 
many cultures were taken. The class was then dismissed 
from Thursday to the following Monday, the room disin- 
fected and cleaned up. For ten days after their return the 
throat of every pupil was examined by the medical inspec- 
tor when they first assembled in the morning, and no pupil 
who had been absent with any suspicious symptoms was al- 
lowed to return until it was proved by a negative culture 
that there could be no danger. As a result of these meas- 
ures not a single case of diphtheria resulted beyond those 
known to have been infected at the time the epidemic was 
discovered. A similar experience with scarlet fever oc- 
curred in the service of the same school inspector within 
two weeks, in which eleven cases resulted from the presence 
in school of one pupil whose illness had been attributed to 
German measles. 

The following tables give the number of cases of diph- 
theria and scarlet fever reported in Boston, by months for 
nineteen years and twenty years respectively, and show that 
when the schools are in session the number of cases is much 
greater than during vacation time. 



8 MEDICAL INSPECTION OF SCHOOLS. 

Cases of diphtheria reported each month for nineteen 
years : 

Years. Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec. 



1878 


241 


178 


135 


102 


58 


114 


65 


44 


87 


106 


98 


125 


1879 


155 


111 


82 


108 


87 


111 


53 


37 


53 


100 


132 


146 


1880 


167 


141 


112 


101 


143 


126 


100 


74 


105 


150 


238 


258 


1881 


179 


163 


190 


140 


142 


143 


108 


85 


103 


162 


135 


130 


1882 


136 


117 


99 


92 


103 


111 


56 


56 


54 


119 


188 


244 


1883 


170 


132 


100 


98 


140 


94 


64 


72 


88 


126 


150 


175 


1884 


130 


90 


87 


81 


111 


95 


50 


61 


77 


130 


137 


163 


1885 


164 


117 


108 


109 


101 


108 


85 


54 


64 


123 


119 


111 


1886 


122 


104 


110 


66 


73 


94 


75 


78 


85 


130 


111 


140 


1887 


128 


93 


96 


101 


75 


68 


53 


40 


53 


112 


100 


130 


1888 


112 


80 


105 


107 


142 


110 


97 


92 


95 


143 


156 


172 


1889 


179 


150 


193 


205 


190 


165 


93 


99 


99 


137 


130 


174 


1890 


203 


189 


156 


164 


144 


114 


73 


69 


75 


96 


75 


117 


1891 


80 


71 


59 


71 


81 


49 


31 


36 


40 


78 


180 


127 


1892 


102 


108 


114 


135 


107 


77 


76 


78 


79 


144 


185 


175 


1893 


152 


114 


116 


70 


86 


111 


88 


102 


89 


194 


160 


183 


1894 


195 


128 


185 


139 


187 


167 


138 


154 


249 


450 


558 


469 


1895 


343 


296 


205 


185 


225 


328 


268 


278 


345 


415 


635 


564 


1896 


381 


403 


302 


304 


346 


352 


300 


256 


296 


461 


498 


466 



Total, 3339 2794 2554 2378 2541 2537 1873 1765 2136 3376 3913 4059 

Cases of scarlet fever reported each month for the last 
twenty years : 

Tears. Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec. 



1877 


262 


227 


181 


176 


117 


67 


28 


25 


16 


61 


70 


104 


1878 


161 


99 


73 


48 


35 


47 


25 


36 


43 


67 


94 


119 


1879 


131 


108 


190 


93 


82 


32 


27 


47 


55 


57 


65 


63 


1880 


60 


36 


47 


29 


32 


35 


19 


10 


29 


44 


89 


67 


1881 


58 


28 


52 


51 


41 


44 


17 


11 


17 


16 


19 


29 


1882 


65 


41 


49 


36 


70 


61 


26 


41 


37 


48 


102 


104 


1883 


123 


82 


83 


104 


101 


103 


65 


89 


85 


214 


168 


195 


1884 


209 


186 


197 


239 


215 


173 


214 


209 


175 


242 


224 


242 


1885 


232 


131 


182 


159 


160 


135 


85 


56 


87 


153 


148 


137 


1886 


155 


126 


144 


151 


115 


99 


56 


52 


43 


58 


82 


68 


1887 


97 


76 


101 


102 


98 


62 


29 


51 


142 


207 


320 


268 


1888 


146 


119 


100 


75 


70 


20 


19 


11 


16 


52 


29 


40 


1889 


48 


29 


77 


59 


53 


34 


15 


15 


17 


32 


36 


49 


1890 


98 


103 


105 


122 


118 


74 


72 


30 


20 


30 


40 


112 


1891 


109 


95 


108 


151 


159 


97 


49 


40 


56 


67 


136 


260 


1892 


290 


291 


447 


335 


370 


217 


124 


86 


100 


183 


226 


269 


1893 


282 


190 


228 


245 


203 


144 


144 


140 


179 


304 


283 


238 


1894 


214 


169 


168 


199 


266 


205 


109 


135 


125 


182 


192 


278 


1895 


231 


174 


184 


139 


137 


123 


94 


82 


91 


127 


120 


113 


1896 


136 


99 


104 


108 


77 


113 


72 


42 


53 


81 


157 


176 



Total, 3107 2409 2820 2621 2519 1885 1289 1208 1386 2228 2600 2931 



MEDICAL INSPECTION OF SCHOOLS. 9 

It will be seen by an examination of the table for diph- 
theria that the average number of cases reported for each 
of the eight school months is 2,772, and for the four months 
of little or no school it is 2,077. In the table for scarlet 
fever it will be found that the average number of cases re- 
ported for each of the eight school months is 2,779, and for 
the four summer months it is but 1,191. 

We do not claim that the closing of the schools is the 
only cause for the largely diminished amount of scarlet 
fever and diphtheria, but we believe that it is one of the 
important factors. Owing to the evident spread of scarlet 
fever and diphtheria in the schools, we recommended, in 
1882, that the school-houses be thoroughly disinfected 
once in two weeks. This proposition was rejected, 
however, on the grounds that it would cost from $5,000 
to $6,000, would be a hardship to the janitors, and that 
it might not effectually prevent the spread of the disease. 
From time to time since that date we have recommended 
to the School Board the need of frequently cleaning and 
disinfecting such parts of the interior of school buildings 
as might become infected, and that the use of many 
objects in common use among the children and Avhich 
might easily become sources of infection, be discontinued. 
A few of these recommendations have been adopted. In 
1890 the Board of Health proposed to furnish the schools 
with daily medical inspection with a view to discovering the 
earliest symptoms of infectious diseases among the children, 
by examining all cases of children sick or complaining from 
any cause in the schools, and giving to the teachers such 
professional advice as is constantly needed for the disposi- 
tion of such children. After four years of unsuccessful ef- 
orts the Board succeeded, under the influence of a severe 
epidemic of diphtheria, and began the work November 1st, 
1894. 

The Board of Health divided the city into fifty districts. 



10 MEDICAL INSPECTION OF SCHOOLS. 

giving an average of about four school-houses and fourteen 
hundred pupils to each district. No difficulty was experi- 
enced in finding Avell qualified and discreet physicians who 
would undertake the duties prescribed ; and the Board se- 
lected and appointed one physician for each district with a 
salary of $200 a year. His duty is to make a visit to each 
master's school daily, soon after the beginning of the morn- 
ing session. The master receives from each of the teachers 
in his district early reports as to the appearance of illness 
in any pupil in his charge. These reports are given to 
the visiting physician, who at once examines the reported 
children and makes a record of his diagnosis and action in 
books furnished by the Board of Health for this purpose 
and kept in the custody of the master. If the visiting phy- 
sician finds the child too ill, from any cause, to remain in 
school, he advises the teacher to send the child home for the 
observation and care of its parents and family physician. 
If the illness is from a contagious disease the child is or- 
dered home and the case reported to the Board of Health. 
The disposition of the sick child while at home, and the 
proper isolation in cases where contagious diseases develop 
in such children, as well as giving them a warrant for re- 
turning to school, depends principally upon the report of 
the school inspector. 

In the examination of the children in school every facility 
is extended to the doctor by the teachers, and he in turn 
reaches a satisfactory conclusion with the least possible de- 
lay or annoyance to any one. There being frequent need for 
looking into the children's throats, we provided the inspec- 
tors with something for a tongue depressor which could be 
used once and destroyed, and thus get rid of the danger of 
communicating any disease from one pupil to another, and 
avoid unfavorable criticism on that score. I have some 
of them here to show you. These little pieces of clean 
pine ai-e made for us at a cost of one-tenth of a cent each. 



MEDICAL INSPECTION OF SCHOOLS. H 

They are without objection in use or appearance, and will 
burn as easily as a match, which is the intended destiny of 
each after being used once. The thermometer is rarely a 
necessity in these examinations, and when used is treated 
with due care. 

The school inspectors do not give professional treatment 
in any case. They merely point out the need of profes- 
sional treatment where the need exists. The treatment it- 
self must be received from the family physician, or in the 
hospitals, or in the dispensaries, and great care is necessary 
to avoid giving offence to physicians and their families. 

It should be remembered that the Boards of Health of 
this State are authorized and required by statute law, to 
take charge of any case of contagious or infectious disease 
which may be dangerous to the public health ; and while it 
is preferred that many cases should remain at home and be 
cared for by the family and the family physician, their 
isolation at home must be satisfactory to the Board of Health, 
and so certified by a medical agent of the Board. So also 
in the discharge of such patients from isolation, the evidence 
of their freedom from the disease, and the safety of their 
return to school or to the public, must be satisfactory to the 
Board of Health and come from its medical agent. For 
this duty the same medical inspectors are serving as agents 
of the Board of Health in the control of infectious diseases 
which are treated at home. We send to each of the school 
inspectors every morning a bulletin of the cases of diph- 
theria and scarlet fever which have been reported during the 
previous twenty-four hours. Each medical officer selects 
the cases reported in his district, visits them to see if they 
are properly isolated, leaves a card for the attending phy- 
sician informing him of the official visit, and reports his 
approval or disapproval of the patient's isolation at once to 
the Board of Health. If the patient is properly isolated 
the inspector places a card on the door of the room to indi- 



12 MEDICAL INSPECTION OF SCHOOLS. 

cate the official designation of the room for the isolation of 
the patient. If the case is not properly isolated, and it can- 
not be commanded at home, he reports the fact to the Board 
of Health, and such patient is taken to the hospital. He 
makes another visit to the patient on the question of dis- 
charge from isolation, and again reports to the Board of 
Health. If it is a case of diphtheria a negative report 
from the laboratory to the Board of Health is necessary, 
and if it is a case of scarlet fever desquamation must have 
ceased, and the fact certified by the agent before such 
patient can laAvfully be released from isolation. The agent 
of the Board is thus held responsible for the proper isolation 
of the patient at home, for recommending the patient's re- 
moval to the hospital when necessary, and for the patient's 
release from isolation. In other words, the Board of 
Health is provided with trustworthy information upon which 
it can act for the best protection of the schools and the pub- 
lic against the spread of infectious diseases. 

This corps of inspectors has become an organized asso- 
ciation, which meets once in two months, to discuss the 
manifold medical questions which arise in the performance 
of their duties. 

The whole number of children examined in 1896, and 
found to be ill, was 8,964. The diseases of which the 
children were suffering were classified as follows : 

Specific Infectious Diseases, 267 

Oral and Respiratory Diseases, 3,934 
Ear Diseases, QQ 

Eye Diseases, 382 

Skin Diseases, 628 

Miscellaneous Diseases, 3,687 

Those who were found to be suffering from infectious 
diseases were, as a rule, unaAvare of the fact, owing to the 
early stage of the disease or to the mildness of the attack. 
Occasionallv one is found who has been prematurely re- 



MEDICAL INSPECTION OF SCHOOLS. 13 

leased from care. All, however, were in a condition to 
spread the disease from which they were suffering. 

There are about 85,000 pupils and over 1,500 teachers 
in the public schools, and about 13,000 pupils in the paro- 
chial schools of Boston which furnishes a wide field and the 
best opportunity for the exercise of professional observation 
and sanitary precautions against the diseases of childhood 
incident to school attendance. This work has now been in 
successful operation in Boston for two years and seven 
months, has constantly grown in favor in the medical pro- 
fession, among the school teachers and in the community at 
large. There is every reason to suppose that under the in- 
fluence of this daily medical attention every teacher will 
become more interested and expert in the outlook for and 
detection of any existing illness amongst the children under 
his or her care. Every parent may feel that his child is 
less exposed to disease while in school, and less likely to be 
ill without immediate attention from teacher or physician 
than was formerly the case. 

This is the first work of its kind performed in this 
country, and, so far as I am able to learn, in the world. 
The nearest approach to it is done in Brussels where, under 
the control of the Bureau of Hygiene, school doctors are 
employed, and to whom the pupils are sent when suspected 
of being ill with infectious diseases. Our work has been 
recently copied in many places in this country, including 
the city of New York, where it has been employed for the 
last three months with complete satisfaction. 

I am satisfied that it would be hard to find a field for 
medical inspection and supervision which presents equal 
facilities for the early detection of diseases, or which offers 
more satisfactory results. 



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